The Chronic Care Model in CQN

System Framework for Great Asthma Care

How to produce continuous, enduring improvements in care for a population?

• Appreciation for care as a system• Flexible improvement model• Sequential building of knowledge

– Testing changes on a small scale– Spread of improvements to similar sites

• Efficient and effective use of data– Usefulness not perfection

Tom Nolan, PhD

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

Focus

L Provost, API

What change can we make that will lead to improvement?

Change Concept: a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement.

L Provost, API

Conceptual, Vague Strategic

Specific Actionable Ideas

Decision support

Use a template

Create an encounter form that includes assessment of control

Incorporate CQN form into flow and try it on two patients next

Monday

Moving from Concepts to Ideas

Simplified Care Model• Registry

• Templates for planned care– (e.g., structured encounter

form)

• Protocols to standardize care– Standard Protocols– Nursing Standing Orders– Defined Care team roles

• Self-management support strategies

CQN Practice Key Driver

GLOBAL CQN AIMWe will build a sustainable quality improvement infrastructure within our practice to achieve measurable improvements in asthma outcomes

Specific From May 2009 to July 2010, we will achieve measurable improvements in asthma outcomes by implementing the NHLBI guidelines and making CQN’s key practice changes

Action Item: Chapters insert their states goals and aim statements

Key Drivers

Use Registry to Manage Population (a sustainable change) *Identify each affected patient at every visit *Identify needed services for each patient *Recall patients for follow-up *General data

Engagement of Asthma Core Team and the practice as a whole *The team is active and engaged in improving practice processes and patient outcomes

Planned Care * Care team is aware of patient needs and work

together to ensure all needed services are

completed

Employ Protocols * Standardize Care Processes

* Practice wide asthma guidelines implemented

Provide Self management Support

* Realized patient and care team relationship

Interventions· Form a 3-5 person interdisciplinary QI Asthma Team

· Formally communicate to entire practice the importance and goal of this project

· Meet regularly to work on improvement (continuously create Improvement Plans)

· All physicians and team members complete QI Basics on EQIPP

· Gain consensus on EQIPPs ‘Overview’ tab and carry out all necessary actions to support changes

· Collect and enter baseline data

· Generate performance data monthly by taking registry data and inputting it into EQIPP

· Communicate with the state chapter and leaders within the organization

· Turn in all necessary data and forms

· Attend all necessary meetings and phone conferences

· Choose and Implement Registry

· Determine staff workflow to support registry

· Populate registry with patient data

· Routinely maintain registry data

· Use registry to manage patient care & support population management

· Select template tool from registry or create a flow sheet

· Determine staff workflow to support template

· Use template with all patients

· Ensure registry updated each time template used

· Monitor use of template

· Obtain patient education materials

· Determine staff workflow to support SMS

· Provide training to staff in SMS

· Assess and set patient goals and degree of control collaboratively

· Document & Monitor patient progress toward goals

· Link with community resources

· Select & customize evidence-based protocols for asthma

· Determine staff workflow to support protocol, including standing orders

· Use protocols with all patients

· Monitor use of protocols

CQN Hi-Leverage Changes

• Use Template (encounter form) for Planned Care

• Implement ‘registry’ to identify and manage children with asthma

• Use Protocols• Adopt Self-management Support

Strategies

Chronic Care Model/CQN High Leverage Changes

Registry Template Protocols Self Management Support

Health System Addressed by each chapter in CQN

Delivery System Design

·Determine staff workflow to support registry use

·Determine staff workflow to support use of template

·Monitor use of template·Determine staff workflow to support protocols, including standing orders

·Monitor use of protocols

• Determine staff workflow to support SMS

• Provide training to staff in SMS techniques

• Document & monitor patient progress toward goals

Decision Support

·Use registry to manage patient care and support population management

·Select template tool from registry or create a flow sheet

·Use template with all patients

·Select and customize evidence-based protocols to office

·Use protocols with all patients

·Assess and document asthma severity and control

·Establish visit frequency protocol

Clinical Information Systems

·Select and install a registry tool

·Populate registry with patient data

·Routinely maintain registry data

·Ensure registry updated each time template used

Self Management Support

· Obtain patient education materials (e.g., asthma action plans)

· Set patient goals collaboratively

· Use Asthma Management plans

Community · Link with community resources (schools, service organizations)

Key Driver: Employing Protocols

1. Use NHLBI evidence-based guidelines at point of careDetermine staff workflow to support guideline use (i.e., protocols including standing orders)

2. Use protocols with all patients3. Monitor use of protocols

Key Driver: Planned Care • Assess and document asthma severity

and control• Prescribe appropriate asthma medications

and monitor overuse of beta agonists• Use Asthma Management plans• Establish visit frequency protocol• Assess and treat co-morbidities• Assess, counsel, and prevent exposure to

environmental triggers

Key Driver: Self-management Support

Provide training to staff in SMS techniques

Set patient goals collaboratively Determine staff workflow to support

SMS Obtain patient education materials

(e.g., asthma action plans) Document and monitor patient progress

toward goals Link with community resources (schools,

service organizations)

Monitoring the Process

• Monthly reports at practice, chapter and national level

• To inform where you need to focus improvement activities/PDSA’s

• Requires work and planning– a few huddles a week to plan, study and identify new theories

Overcoming Challenges

• Ask questions of Collaborative faculty• Share challenges on Listserv• Find links, tools and resources on the

Extranet• Request consultation from another

practice team

Putting It All Together

• Create a strong practice team• Clarify what you are are trying to

accomplish• Try high-leverage changes• Measure progress• Refine and customize changes• Share and integrate learning